Quality Payment Program: Year 2

July 7, 2017

The long anticipated Medicare Access and CHIP Reauthorization Act (MACRA) 2018 proposed rule was released on June 20. As you know, MACRA established the Quality Payment Program (QPP) which offers two tracks for eligible clinicians: The Merit Based Incentive Payment Systems (MIPS) and Alternative Payment Models (APMs). CMS also released a shorter fact sheet (26 pages) on the proposed rule that you may want to review.

General Program Requirements

Significant increase to the low-volume threshold from ≤ $30,000 in Medicare revenue or ≤ 100 Medicare patients for 2017 to ≤ $90,000 in Medicare revenue or ≤ 200 Medicare patients for 2018. According to CMS calculations, this new low-volume threshold, would exclude about 585,560 clinicians from MIPS. As a result, of this exclusion and others, CMS approximates that just 37% of the 1.5 million clinicians billing under Medicare will participate in MIPS.

Clinicians and groups below the low-volume threshold will have no option to participate in MIPS for performance year 2018 if they report on their own. However, CMS is suggesting that in the future these clinicians/groups have the ability to opt-in to MIPS, even if they fall beneath the low volume exception.

Payment adjustment for the 2020 payment year ranges from – 5% to + (5% x scaling factor) as required by law. (The scaling factor is determined in a way so that budget neutrality is achieved.)

Exceptional performer threshold remains at composite score ≥ 70 and eligible for part of the allotted $500 million

Performance threshold set at 15 for QPP year 2 of MIPS. While this is slightly higher than QPP year 1’s performance threshold of 3, it should still be easy for the vast majority of participating ECs to earn a Composite Performance Score above 15.

Any EC or group who is in a small practice (15 clinicians or less) will receive 5 points added to the final score, as long as the EC or group submits data on at least 1 performance category in the applicable performance period.

Adding bonus points in the scoring methodology for:

Caring for complex patients

Using 2015 Edition CEHRT exclusively

Implement an optional facility-based scoring mechanism based on the Hospital Value Based Purchasing Program which would be available only for facility-based clinicians who have at least 75% of their covered professional services supplied in the inpatient hospital setting or emergency department. The facility-based measurement option converts a hospital Total Performance Score into a MIPS Quality performance category and Cost performance category score.

Apply an adjustment of up to 3 bonus points by adding the average Hierarchical Conditions Category (HCC) risk score to the final score. Generally, this will award between 1 to 3 points to clinicians based on the medical complexity of the patients they see.

Virtual Groups

For QPP year 2, those clinicians who fall beneath the low-volume threshold but who would like to participate must either join an actual medical group whose volume is sufficient enough to qualify the group for MIPS or, participate in a “virtual” group.

Option 1 (actual group) is report as a group (identified by Tax ID Number) if the group’s revenues and patient count exceed the low-volume threshold.

Option 2 is to participate in the newly proposed voluntary “virtual groups” which would allow several small practices, (with separate Tax ID Numbers) to join together for the purposes of qualifying for a MIPS score.

Virtual groups are available as an option for solo practitioners and groups of 10 or fewer eligible clinicians (EC) who are below the low-volume threshold who enter into a “virtual group” with other solo practitioners or groups of less than 10 clinicians.

The definition of non-patient facing MIPS EC/group remains the same, however CMS has now applied that to virtual groups.

Quality Performance Category

Allow individual MIPS ECs and groups to submit measures and activities through multiple submission mechanisms within a performance category as available and applicable to meet the requirements of the Quality, Improvement Activities, or Advancing Care Information performance categories.

Quality measures that do not meet data completeness criteria (remains at 50%) will get 1 point instead of 3 points, except that small practices will continue to get 3 points.

CMS proposes to use a cap of 6 points for a select set of 6 topped out measures.

Rewards improvement in performance (applicable to the Quality and Cost performance categories only) for an individual MIPS EC or group for a current performance period compared to the prior performance period. Improvement scoring will be based on the rate of improvement so that higher improvement results in more points, particularly for those improving from lower performance in the transition year.

Up to 10 percentage points available in the Quality performance category

Improvement Activities Performance Category

CMS proposes adding a new improvement activity that MIPS ECs could choose if they’re using AUC through a qualified clinical decision support mechanism for all advanced diagnostic imaging services ordered.

The number of required Improvement Activities remains the same, however, CMS is proposing additional activities. Also, for group participation, only 1 MIPS EC in a TIN has to perform the Improvement Activity for the TIN to get credit. CMS is soliciting comments on alternatives for a future threshold.

Advancing Care Information Performance Category

Reweighting the Advancing Care Information performance category to 0% of the final score for ambulatory surgical center (ASC)-based MIPS ECs.

Allow MIPS ECs to use either the 2014 or 2015 Edition CEHRT in 2018; grants a bonus for using only 2015 Edition CEHRT.

Cost Performance Category

CMS will again not factor the Cost category score into the ECs/group’s overall composite score so overall performance category weighting would be as follows: